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Top Ten Things Every Clinician Should Know About the 2018 Cholesterol Guidelines

The American Heart Association / American College of Cardiology (AHA/ACC) Task Force recently published the 2018 Guideline on the Management of Blood Cholesterol. The guidelines writing committee had representation from 12 organizations, including the National Lipid Association, American Diabetes Association, and the American Pharmacists Association — all of whom endorsed the guidelines. The previous guidelines (published in 2013) were intended to answer some specific clinical questions and significantly changed our approach to treatment. The 2018 guidelines provide a more comprehensive set of recommendations, akin to the (older) National Heart, Lung, and Blood Institute Adult Treatment Panel (ATP) III guidelines last published in 2002!

Guest Authors:  Dawn Fuke, Pharm.D., BCPS, and Zach Conroy, PharmD, BCACP

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Another Attempt to ARRIVE at an Answer Using Aspirin for Primary Prevention

Daily low-dose aspirin has long been considered a “wonder drug” for its cardioprotective effects, particularly in patients with pre-existing cardiovascular and cerebrovascular disease; however, despite decades of research, the use of aspirin to prevent a first event is less certain. In 2014, the Food and Drug Administration (FDA) responded to a citizen petition requesting the labeled indications for low dose aspirin be updated to include primary prevention. The FDA concluded that the evidence “fail[ed] to establish that aspirin reduces the risk of primary myocardial infarction (MI) in patients with a coronary heart disease (CHD) risk of 10% or more for over 10 years.” The Asprin to Reduce Risk of Initial Vascular Events (ARRIVE) study is intended to address this gap in our knowledge.

Guest Authors:  Amy St. Amand, PharmD, BCPS and Christine Borowy, PharmD, BCPS

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Does a “One-Size-Fits-All” Aspirin Dosing Approach Still Hold WEIGHT?

Personalized medicine is at the forefront of health care today, focusing on how best to tailor the treatment approach to each person. But should we be thinking about personalizing the approach for prevention as well?  The one-dose-fits-all approach has been used in nearly all aspirin studies.  What is poorly understood is the influence of body weight.  Perhaps the reason why aspirin has resulted in only modest benefits in clinical trials might be related to under (and over) dosing based on patient weight.

Podcast Case:  Weight-based Dosing of Aspirin

Guest Author:  Marina Maes, PharmD, BCPS

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Aspirin for Primary Prevention of CV Events in Diabetes - Is the Evidence ASCENDing?

Aspirin is no doubt beneficial in patients with overt vascular disease for the secondary prevention of myocardial infarction, stroke, or cardiovascular death. However, evidence supporting use of aspirin for primary prevention in patients who have not had a cardiovascular event is far less compelling. The clinical uncertainty of aspirin use for the primary prevention of CV events in patients with diabetes is reflected in the different recommendations in current guidelines. The investigators of the ASCEND (A Study of Cardiovascular Events in Diabetes) trial set out to determine the safety and efficacy of daily aspirin use in patients with diabetes without known occlusive arterial disease.

Podcast Case:  ASA Use in DM - Evidence ASCENDing?

Guest Author:  Kirstie Perry, Pharm.D.

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LDL Limbo: How Low is Too Low?

There has been significant debate regarding the safety of achieving very low LDL-C levels, including a potential negative impact on cognitive function. The current ACC/AHA guidelines (circa 2013) suggest decreasing the statin dose in patients with two consecutive LDL-C levels below 40 mg/dL based on expert opinion. The lack of evidence has been a major challenge for clinicians and it is unclear whether medication doses should be reduced in high-risk patients who may benefit from very low LDL-C levels.  A recently published meta-analysis sought to address this clinical dilemma.

Podcast Case: Very Low LDL Case

Guest Authors:  Apryl Anderson, PharmD and Dave Dixon, PharmD, BCPS, BCACP, CLS, CDE

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Top Ten Things Every Clinician Should Know About the 2018 Antithrombotic Therapy Atrial Fibrillation Guidelines

The American College of Chest Physicians (ACCP) recently updated their guideline recommendations for the use of antithrombotics for the prevention of stroke in patients with atrial fibrillation (aka the Chest Guidelines).  Find out what's new, who shouldn't receive treatment based on the CHA₂DS₂-VASc score, and why the guideline panel recommends calculating a patient's SAME-TTR score.

Guest Author:  Dylan Lindsay, PharmD

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Maybe Old is Gold? Newer Insulins Might Not Be Better – Just More Expensive

Fredrick Banting, the Canadian scientist who discovered insulin in 1921 and sold the patent for just $1 to the University of Toronto and made it available to pharmaceutical companies royalty-free, would be disappointed to know that the high cost of insulin is now a major barrier to treatment. The average price of insulin has nearly tripled, from $4.34/ml in 2002 to $12.92/ml in 2013. Insulin’s high cost affects everyone: (1) uninsured patients, (2) insured patients with high co-payments and deductibles, (3) Medicare beneficiaries with coverage gaps and fixed income, and (4) everyone else paying higher premiums to offset the insurers’ expenditures. Are the newer insulins really worth the extra cost?  A new study by investigators at Kaiser Permanente Northern California suggests that most patients can safely use NPH insulin instead of more expensive insulin analogs.

Download the podcast patient case:  NPH vs Insulin Analogs

Guest Authors:  Jaini Patel, PharmD, BCACP and Regina Arellano, PharmD, BCPS

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Using Controllers PRN for Mild Persistent Asthma – An Oxymoron?

Two recent studies challenge our current approach to managing patients with mild persistent asthma. When patients with asthma are prescribed inhaled corticosteroids (ICSs), we instruct them to use the medication daily. In patients with persistent asthma, guidelines recommend maintenance therapy, with either an ICS or a combination ICS/long-acting beta-agonist (LABA), plus a short-acting beta-agonist (SABA) as needed for rescue treatment.  The Symbicort Given as Needed in Mild Asthma (SYGMA) 1 and SYGMA 2 trials challenge the traditional approach comparing combination ICS/LABA (budesonide-formoterol) as needed to traditional ICS maintenance with SABA rescue therapy.

Guest Author:  Brittany Schmidt, PharmD, BCACP

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The ZOE Trials – The Herpes Zoster Recombinant Subunit Vaccine — It’s Time to Upgrade!

We now have two vaccinations to protect against herpes zoster — a live-attenuated vaccine (Zostavax) and the new recombinant subunit vaccine (Shingrix). While the live-attenuated vaccine has been available for more than a decade and a CDC-recommended vaccine in older adults, only one in three eligible patients have received it.  Based on the results of two recently published studies, the new recombinant subunit vaccine appears to provide substantially improved efficacy and duration.

Guest Author:  Katherine Montag Schafer, PharmD, BCACP

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Are You REAL-ly Paying Attention? The Importance of Attention Controls

Critically-evaluating the literature is essential to engage in evidence-based practice.  A key component of assessing studies involves determining whether the comparator groups are appropriate.  Most pharmacists are familiar with the use of placebos for evaluating drug treatments, but how many of us have considered the comparator groups in behavioral interventions?  For these situations, employing attention placebo controls (APC) is important.

Guest Authors:  Elizabeth A. Cook, PharmD, BCACP, CDE, AE-C and Rachel A. Sharpton, PharmD, BCACP

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